Some

authors believe compensatory sweating to be more of a
problem after treatment for axillary as opposed to palmar
hyperhidrosis

9,23

.

Gustatory sweating occurs on eating hot or spicy food.

Its incidence varies from 1 per cent

20

to 51 per cent

9

, but

it is generally underreported as both clinicians and patients
do not view it as unduly troublesome. The exact mechanism
is not clear.

In the early days of open operations, Horner's

syndrome was the hallmark of successful extirpation of
the sympathetic chain, but this is now regarded as a serious
complication. Comparison of its incidence in different
series is made difficult by the different definitions of the
syndrome used by authors. Mild Horner's syndrome may
be marked by a miosis detectable only on close examination,
but when severe ptosis is obvious. Temporary ptosis is

Copyright

 2004 British Journal of Surgery Society Ltd

www.bjs.co.uk

British Journal of Surgery 2004; 91: 264-269

Published by John Wiley & Sons Ltd

Drawbacksof endoscopic thoracic sympathectomy

267

relatively common, perhaps as frequent as 1 per cent,
but resolves over weeks or months. In the Japanese
series the incidence of permanent Horner's syndrome was
0

·3 per cent

13

. In an early series from Vienna the incidence

was 3

·5 per cent; this was attributed to thermal injury of

the stellate ganglion because of the high level at which the
chain was divided

24

.

Rhinitis has been described by some authors as

a consequence of ETS, with an incidence of up to
10 per cent

9

, but ETS has also been recommended as

a treatment for chronic rhinitis

25

. These contradictory

positions cannot be reconciled at present. Phantom
sweating, a feeling of sweating (or blushing) without actual
sweating, has also been reported as a sequela of ETS. It was
first noted in patients undergoing open sympathectomy

26

.

A number of cardiorespiratory effects have been

associated with ETS. Occasionally patients complain
of shortness of breath and of lethargy following
sympathectomy. These features may be difficult to quantify
but, in a small study of 18 patients, bilateral T2-4 ETS led
to a reduction in resting and maximal heart rate but without
effect on maximal workload

27

. The effect of surgery on

bronchial reactivity is uncertain. Persistent bradycardia
has been described after bilateral T2 sympathectomies.
Permanent pacing was required in one patient 2 years
after the procedure to treat persistent symptomatic
bradycardia

28

. Other rare complications include abnormal

suntanning and extensor policis longus paralysis

29

.

Medicolegal aspects

It is not surprising that significant medicolegal activity
surrounds ETS. In the UK most operations are carried
out by vascular surgeons. The Vascular Surgical Society
of Great Britain and Ireland (VSSGBI) has audited
medicolegal claims made during the period 1990-1999

30

.

Of 424 claims identified, 12 followed ETS (W. B.
Campbell, personal communication). There were three
claims for postoperative pneumothorax (one of these also
involved phrenic nerve damage). Three patients had not
been warned of compensatory hyperhidrosis. A further
three claims related to neuralgic complications (brachial
plexus injury, intercostal neuralgia and paraesthesia).
The final three involved Horner's syndrome, scarring
and restricted movement, and (somewhat surprisingly) a
fractured shoulder.

One of the authors (A.E.P.C.) has previously reported

four instances of injury on which he has given an expert
opinion for legal purposes

31

. Two arose from double-

lumen anaesthesia (one death and one brain injury), one was
a successfully treated subclavian artery laceration, and one

involved severe compensatory hyperhidrosis. Interestingly,
only one of these appeared in the VSSGBI audit, suggesting
that the medicolegal issue may be even greater than is
currently appreciated.

Comment

This review reveals a striking similarity between reported
series, the outcomes from small individual studies

20

being

broadly similar to those of large reports